Provider Demographics
NPI:1922116482
Name:DAVILA, JOSE (MD)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:DAVILA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5525 GROSSMONT CENTER DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3009
Mailing Address - Country:US
Mailing Address - Phone:858-499-2600
Mailing Address - Fax:619-644-6899
Practice Address - Street 1:5525 GROSSMONT CENTER DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3009
Practice Address - Country:US
Practice Address - Phone:858-499-2600
Practice Address - Fax:619-644-6899
Is Sole Proprietor?:No
Enumeration Date:2006-08-26
Last Update Date:2013-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41066207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A410660Medicaid
CAWA41066AMedicare ID - Type Unspecified
CA00A410660Medicaid